The stark, stubborn racial disparities in maternal healthcare
We need political will, and action, to fix this, says Tracey Bignall, senior policy and practice officer at the Race Equality Foundation, in the latest The Backlash Q&A.
It seems like every other week there is yet another grim headline about the state of Britain's maternity services — more failing units, more families with stories of trauma, or worse. On paper, maternity services in this country are focussed on the individual. In practice, it is increasingly difficult for clinicians to provide truly patient-centred care. When I gave birth to my second daughter a few years ago, I had the kind of experience that reveals the tensions in a maternity service stretched to breaking point.
Today, the New Statesman (aka my day job) published an article I have been working on for longer than I care to admit about what is at stake if this crisis continues. Thirty years ago, the UK government transformed maternity care, shifting power from the institution to the individual. This shift was radical, progressive and revolutionary. It was about women’s rights and politics, as much as it was about health.
And maternal health remains a political matter. Aside from the issue of power and choice over care, gaps in access to healthcare and inequality of outcome tell us much about the intersection of ethnicity, socioeconomic status, and geography. In fact, a shocking element of Britain’s maternity care crisis is the stark racial disparity in maternal mortality rates. In the UK, Black women are four times more likely to die from childbirth or pregnancy than white women. This figure has been a constant for two decades, as an April report by the House of Commons’ Women and Equalities Committee states. “Significant disparities also exist for women of Asian and mixed ethnicity,” the report says, and women in the most deprived parts of the country are 2.5 times more likely to die in childbirth or pregnancy than in the least deprived areas.
In the latest The Backlash Q&A, Tracey Bignall, Senior Policy and Practice Officer at the Race Equality Foundation (who I also interviewed for my NS piece), discusses why this disparity persists, and what can be done about it.
The Backlash: What do the women you speak to about their experience of maternity services tell you about racism that they encounter?
Tracey Bignall: We have spoken to organisations working and supporting Black, Asian and minority ethnic women, such as The Motherhood Group, Maternity Action, and women directly from African groups such as Somali, Caribbean, and minority ethnic communities about their experiences. These reinforce the evidence outlined in the Women and Equalities Committee report, and outlined by others including the Birthrights Racial Justice Inquiry into Maternity Services, Fivexmore, Muslim Women’s Network, the charity Bliss’ exploration of South Asian families’ experiences of neonatal care, as well as individual women themselves.
Concerns are expressed about issues including lack of respect; practice informed by stereotypical assumptions of Asian and Black women; not being listened to; poor perinatal mental health support; lack of understanding of appearance of medical conditions on black skin tones; stereotyped assumptions about pain thresholds and not being given timely pain relief; lack of interpreting and language support; lack of choice in where and how women give birth; being left unattended; presumption of wider family support; and basing decisions on place of birth by the ethnic make-up of staff and recommendations from other Black, Asian, and minority ethnic women on racism in the hospital and how they were treated.
The Backlash: The April report found that women in the most deprived areas of the country are 2.5 times more likely to die in childbirth or pregnancy than those in the least deprived areas. What does this tell us about problems of access to healthcare for women?
Tracey Bignall: Deprivation is a key contributor to health inequalities and the evidence is that some Black, Asian, and minority ethnic communities are overrepresented in living in poverty, working in unstable employment and earning low incomes, and living in overcrowded homes with poor access to green spaces, and are impacted by these wider determinants of health. Areas of deprivation need more support to ensure women have access to the safe and equitable services available to women living in more affluent areas.
The Backlash: How do you explain the racial disparity in maternal death rates not budging in twenty years?
Tracey Bignall: Unfortunately, the Women and Equalities Committee report has not outlined anything new. This evidence has been consistent and known to maternity services providers for a very long time.
MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK — the national programme which conducts surveillance and investigates the causes of maternal deaths, stillbirths, and infant deaths — does not identify reasons for these disparities, but does mention underlying conditions and deprivation as possible contributory factors. MBRRACE-UK does not give any clear solutions but tends to suggest the need for further research to understand the disparities in outcomes for Black and Asian women.
However, is there a need for even more research? We know the NHS Long Term Plan in 2019, in an attempt to address maternity inequalities, focused on implementing continuity of care [the principle that a woman be seen by the same midwifery team where possible throughout her pregnancy], which had targets to help improve outcomes for the most vulnerable mothers and babies. This included 75 per cent of women from Black, Asian, and minority ethnic communities and those living in the most deprived areas receiving this model of care during pregnancy, labour, and the postnatal period by 2024.
In fact, the need to address racial disparities was highlighted by the NHS as recently as 2020. During the Covid-19 pandemic, given the overrepresentation of Black pregnant women being hospitalised with coronavirus, this prompted targeted advice and action to NHS Hospital Trusts to address risk factors for Black, Asian, and minority ethnic pregnant women, given what was already known about their health experiences and outcomes.
The then-Chief Midwifery Officer for England, Jacqueline Dunkley-Bent, in a letter to Trusts, outlined action to address these racial inequalities, including increasing clinical support of at-risk pregnant women, tailored communications for minority ethnic women, encouraging uptake of vitamins (such as vitamin D) and supplements, and better recording of ethnicity and other risk factors on maternity information systems.
At the same time, the Royal College of Obstetricians and Gynaecologists had begun work to address racial disparities and racism in maternity through a taskforce. However, as yet, these actions have not reduced the disparities.
Continuity of care is highlighted as a model that can improve outcomes for women. But despite, a commitment in the NHS Long Term Plan to help address inequalities experienced by Black, Asian, and minority ethnic women, in 2020 inspections by the Care Quality Commission (the independent regulator of health and social care in England) that looked specifically at the safety of maternity services found that “none of the continuity of care teams had an explicit focus on supporting women from Black and minority ethnic groups.” A concluding remark was that maternity services need to “improve how they engage with, learn from, and listen to the needs of women, particularly women from Black and minority ethnic groups” in trying to address inequalities.
There is also the Core20PLUS5 agenda to reduce inequalities. This involves implementing midwifery continuity of care, particularly for women from minority ethnic communities and from the most deprived areas. However, it is still concerning that there has been a removal of targets by NHS England in 2022 for implementing continuity of care. This action is likely to impact on responding to the needs of Black, Asian, and minority ethnic women as a means to address these inequalities.
Meanwhile, the current NHS England three-year delivery plan for maternity and neonatal services has an underlying theme to address inequalities in access, experience, and outcomes of services, which includes access to interpreting services, implementing anti-racism measures for staff, and monitoring data to address differences in outcomes for women of different ethnic backgrounds. But we cannot detract from the fact that racism and discrimination are underlying factors that must impact on these outcomes for Black and Asian women. First-hand information on where racism and stereotyped perceptions have informed clinical practice — leading to poor experiences of care for many women — is often shared publicly.
What is needed is the political will, and the action, to tackle racial discrimination and how this influences practice. There needs to be improved ethnicity recording and personalised and safe care. Until there is focused action to address racial discrimination nationally, and by maternity services providers, it is likely that these statistics will continue, showing racial disparities in maternal mortality and poorer outcomes for Black, Asian, and minority ethnic pregnant women.
The Backlash: England has had a long line of major maternity care reviews and strategies — such as Changing Childbirth in 1993, Better Births in 2016, the more recent three year delivery plan for maternity and neonatal services. How much has racial disparity in maternal mortality been highlighted in these?
Tracey Bignall: There was much focus on health inequalities, poor outcomes for Black, Asian, and minority ethnic communities, and how these inequalities could and should be addressed, during the devastating impact of the Covid-19 pandemic. However, the focus on addressing inequalities is not specific enough about addressing ethnic health inequalities. For example, the NHS three-year delivery plan for maternity and neonatal services has four themes. Under the theme “Listening to and working with women and families, with compassion”, there is an objective to reduce inequalities for mothers and their babies. One action is for Integrated Care Systems — partnerships of organisations that jointly plan and deliver NHS care — to commission local maternity and neonatal voice partnerships (grassroots groups of service users and clinicians) to be more reflective of the ethnic diversity of the local population. But it is not clear whether Black, Asian, and minority ethnic women are aware of the role of these partnerships and what is being taking to reach out and engage with them. Anecdotally, Black, Asian, and minority ethnic families are still unrepresented through these partnerships.
It is questionable how much weight is being given to addressing racial disparities. There is reference to specific resources, plans, and anti-racist approaches that organisations should take to tackle racial inequalities and discrimination for staff. However, action to address racial inequity for pregnant women in experiences and outcomes is generic. Without specific objectives and targets, there can still be inconsistency in the action taken to address disparities.
The Backlash: In the US there is a similarly stark gap, with Black women three times more likely to die from a pregnancy-related cause than white women, according to the CDC. This is striking, especially given how different the US and UK health systems are. How do you explain it?
Tracey Bignall: The answer to this, in our opinion, is similar to the answer to why the racial disparity in the UK has not shifted in 20 years — underlying conditions and deprivation are possible contributory factors, alongside wider determinants of health, structural inequality, and institutional discrimination. In both countries, socioeconomic disadvantages, including lower income levels, and limited access to quality healthcare can lead to poorer overall health outcomes, including higher maternal mortality rates. In some regions or communities, minority groups may have limited access to healthcare facilities or face barriers in receiving proper care. This can result in delayed or substandard medical attention, leading to higher risks during pregnancy and childbirth. Efforts to address and reduce these disparities require a comprehensive approach that includes improving access to quality healthcare, increasing health literacy in vulnerable communities, promoting cultural competence among healthcare providers, and addressing socioeconomic inequalities. Additionally, data collection and research are essential for understanding the root causes of these disparities, and developing targeted interventions to address them.